Uterus endometrial and myometrial malignancies

Background

Total abdominal hysterectomy (TAH) is undertaken for the treatment of a number of medical conditions, ranging from prolapse of the uterus to benign or malignant lesions in the body of the uterus, cervix and/or ovaries.^1-5 Obstetric removal of the uterus may occur due to intractable haemorrhage, rupture or abnormal placental implantation.⁵

This protocol includes hysterectomy for endometrial and myometrial malignancies. See separate protocols for hysterectomies for invasive tumours of the cervix and benign conditions.

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Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. See overview page for more detail on identification principles.

See general information for more detail on specimen handling procedures.

Inspect the specimen and dictate a macroscopic description.

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External Inspection

Orientate and identify the anatomical features of the specimen.

Photograph the intact specimen if required.

Describe the following features of the specimen:

Procedure

Record as stated by the clinician.

Specimen integrity

• Intact
• Opened, describe
• Morcellated⁴, describe

Laparoscopic specimens may be received in pieces and should be orientated where possible to resemble intact uterus.⁴

Anatomical components included (more than one may apply) and specimen size (mm)

Describe and measure the anatomical components present.¹

Refer to relevant specimen protocol(s) for more detail.

Uterus

• Measure in three dimensions^1,6
• Mid-line fundal-serosa to ectocervix
• Maximum intercornual
• Maximum anterior to posterior

Cervix

• Measure in two dimensions, anterior-posterior (12 to 6 o’clock) x transverse (3 to 6 o’clock ).

Serosal surface^4,6

Describe:¹

• Normal
• Abnormal
  • Nodules
  • Adhesions
  • Perforation present
  • Tumour present

Uterus weight (g)^1,6

• Weight of specimen without ovaries or fallopian tubes

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Dissection

The surgical margins and any abnormal serosal surfaces of the uterus should be painted with ink to assess areas suspicious for tumour involvement.

Upon receipt of the specimen, the uterus must be promptly opened out into two halves to ensure adequate fixation.

The separate halves are immersed in formalin with the endometrial surfaces exposed in order to ensure adequate fixation.

Traditionally the uterine cavity is opened coronally although in some institutions a sagittal technique is used. Whatever technique is used the key point is to remember that the method should allow for adequate examination, measurement and sampling of the tumour.

Once the uterus is fixed and described, each half can be rotated and transversely sectioned sequentially to assess tumour penetration anteriorly and posteriorly in three dimensions.

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Internal Inspection

Describe the cut surface appearance of the uterus including the following items⁴

Tumour

• Absent
• Present
  • Number; if more than one tumour, designate and describe each tumour separately

Tumour site^1,6

• Endometrium
  • Anterior
  • Posterior
  • Fundal
  • Left lateral wall
  • Right lateral wall
• Cornual recess
  • Left
  • Right
  • Isthmus
• Myometrium
• Other, describe

Tumour size (mm)

• In three dimensions¹

Endometrial tumours should be measured superior-inferior x transverse x thickness, where thickness is total of exophytic plus endophytic tumour.¹

Tumour appearance

• Exophytic
• Endophytic
• Haemorrhagic
• Necrotic

Myometrial invasion

• No
• Yes
  • Maximum depth of invasion (mm)⁶
  • Thickness of adjacent normal myometrium (mm)^1,6
  • Minimum distance to serosal surface (mm)

Endometrium

• Thickness (mm)

Other endometrial abnormalities, residual endometrium

• Absent
• Present, describe
  • Polyp(s)
  • Atrophy
  • Other, describe

Distance to margins (mm)

• Distance of tumour to the inferior surgical margin (mm)¹

Cervical involvement

Specify if tumour is in continuity with endometrial lesion:⁶

• No
• Yes

Measure (mm):¹

• Tumour size in three dimensions (superior-inferior x transverse x thickness where thickness is exophytic plus endophytic)¹
• Distance of tumour to inferior surgical margin¹
• Maximum depth of cervical wall invasion¹
• Thickness of uninvolved cervical wall (mm)¹

See separate protocol for invasive tumours of the cervix.

Other abnormalities

Leiomyomas with atypical macroscopic features require thorough sampling to exclude malignancy. See separate protocol for benign uterus for more detail.

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Processing

Dissect the specimen further and submit sections for processing according to the diagram provided.

Submit representative sections of:

• Cervix, including transformation zone if uninvolved, at least two blocks, one midline incision each from:
  • Anterior lip
  • Posterior lip
• Ovaries, fallopian tube one block of right and left. More thorough sampling will be required for serous carcinoma or familial cancer syndrome specimens.
• Submit left and right parametrium in its entirety, shave sections.
• Tumour demonstrating deepest point of penetration, relationship with serosa and surgical margin(s)
• Large endometrial tumour, contiguous sections containing the most inferior part of the tumour and the external cervical os (to allow microscopic confirmation of any cervical stroma involvement). If tumour is present, include closest cervical stromal margin.
• Cornu, sections from both left and right, if involved
• Isthmus (“lower uterine segment”), longitudinal section to exclude cervical extension of tumour.
• Endometrium, representative sections of uninvolved background tissue

Submit all peritoneal biopsies in their entirety, serially sectioned if >4mm (usually received separately). See also gynaecological small biopsy protocol.

Submit all lymph nodes and identify the site of each.

Record details of each cassette.

An illustrated block key similar to the one provided may be useful.

Block allocation key

Cassette id	Site	No. of pieces
A	Anterior cervix
B	Posterior cervix
C	Left ovary and fallopian tube
D	Right ovary and fallopian tube
E	Left parametrium, shave section
F	Right parametrium, shave section
G-J	Tumour,demonstrating deepest point of penetration, relationship with serosa and/or surgical margins
K-L	Left and right cornu if involved
M	Isthmus, longitudinal section or contiguous sections to include inferior part of the tumour and cervical os
N	Background endometrium

 

Acknowledgements

Drs Kerryn Ireland-Jenkin and Marsali Newman for their contribution in reviewing and editing this protocol.

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References

1. Mulvany N, Allen D, Narayan K and Stewart C. Endometrial cancer structured reporting protocol, The Royal College of Pathologists of Australasia, Surry Hills, NSW, 2011.
2. Ganesan R, Singh N and McCluggage WG. Dataset for histological reporting of endometrial cancer, The Royal College of Pathologists, London, 2014.
3. Wilkinson N and McCluggage WG. Datasets for the histopathological reporting of neoplasms of the ovaries and fallopian tubes and primary carcinomas of the peritoneum, The Royal College of Pathologists, London, 2011.
4. McCluggage WG, Fisher C and Hirschowitz L. Dataset for histological reporting of uterine sarcomas, The Royal College of Pathologists, London, 2011.
5. Brown L, Andrew A, Hirschowitz L and Millan D. Tissue pathways for gynaecological pathology, The Royal College of Pathologists, London, 2008.
6. Heatley MK (2008). Dissection and reporting of the organs of the female genital tract. J Clin Pathol 2008;61(3):241-257.